MassHealth Provider Directory, Provider File Maintenance, and Revalidation

This is a part of the MassHealth Provider Handbook

MassHealth Provider Directory

MassHealth has an online directory that lists demographic information for Behavioral Health providers, specialists, and providers in the Primary Care Clinician Plan and Primary Care Accountable Care Organizations. The information listed in the MassHealth Network Provider Directory is based on MassHealth Provider file information. Therefore, providers need to make sure that they keep their information up to date.

MassHealth Provider ID and service location (PID/SL)

Each provider’s NPI is stored in MassHealth’s Medicaid Management Information System (MMIS) with a corresponding MassHealth provider ID and service location (PID/SL). This PID/ SL is 10 characters, made up of a 9-digit base number and an alpha service location letter (e.g., 123456789A). The provider’s PID/SL will be displayed on MassHealth reports as well as correspondence and remittance advices.

Provider File Maintenance

Providers must notify MassHealth of any changes in their information. Examples of changes include corporate/practice structure, change(s) in licensure, closure or opening of new location, change of address, etc.

Each MassHealth provider must notify the MassHealth agency prior to or no later than the date of the change. Failure to do so constitutes a breach of the provider contract which may be subject to fines or termination. See the regulations at 130 CMR 450.222 and 130 CMR 450.223(B):

Some of the ways that providers can report their changes to MassHealth:

Pharmacy/LTSS providers:

• Contact the appropriate vendor for Pharmacy/LTSS (please see the important Information section for contact information)

Dental providers:

• Dental providers must notify the DentaQuest credentialing department of all changes in writing via email at MassHealthEnrollment&[e-mail]. Additional documentation or paperwork may be required.

Other providers:

• Submit an update request on the Provider Online Service Center (POSC). Changes made via the POSC may still require additional documentation or paperwork.

For more information regarding provider enrollment and credentialing, including change of provider address information, please go to the MassHealth Provider Enrollment and Credentialing (PEC) web page.

Provider File Integrity (MMIS)

Per 130 CMS 450.223(B), all providers are required to notify MassHealth of any change in any of the information submitted in the application. Failure to do so constitutes a breach of the provider contract.

Providers can notify MassHealth and submit a request to update their provider file through the POSC (non-LTSS providers) and though the LTSS Provider Portal (LTSS providers). Some changes are significant (i.e., change of business address or change of ownership) and may require a new application to be submitted.

MassHealth Provider Revalidation

MassHealth providers need to revalidate their information at least every five years.

Section 6401 of the Affordable Care Act established a requirement for Medicare and Medicaid to revalidate enrollment information for all enrolled providers, regardless of provider type, under new enrollment screening criteria at least every five years. MassHealth will select providers each month for revalidation based on their date of enrollment.

As part of the required revalidation process, MassHealth must revalidate the enrollment information of all enrolled providers and site locations. Other information such as Federally Required Disclosures Form (FDRF) may be required. Providers are notified by MassHealth when it is time to complete their revalidations. Revalidation is completed on the POSC (non-LTSS providers) and the LTSS Provider Portal (LTSS providers). See Section 6401 of the Affordable Care Act, 42 CFR 455.414 and 42 CFR 455.104(c) (l) (iii).

Providers have 45 days from the date of the revalidation letter to complete the revalidation process. Failure to complete revalidation in a timely fashion will result in sanctions. Sanctions may include, but are not limited to, administrative fines and suspension or termination from participation in MassHealth.

Learn more about Revalidation here.

 

Dental Providers

Network providers are recredentialed every 5 years.

Dental providers and businesses will be notified by DentaQuest when it is time to recredential. Dental providers and businesses will be required to complete a recredentialing application utilizing App Central. Questions related to recredentialing can be directed to the DentaQuest Provider Enrollment and Credentialing team at MassHealthEnrollment&[e-mail] or [phone].

Date published:	July 29, 2022